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Steve E. Bishop, M.D.

By: Steve E. Bishop, M.D. on October 28th, 2020

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COVID-19 Update 10/28: Cases Rising, Antibodies, Travel in 2021, and More

COVID-19 | Facebook Live Recap

On this week's COVID-19 update, Dr. Steven Bishop discussed the rising cases we are seeing now in 36 states, whether it's a bad thing that antibodies might decline over time, the prospect of emergency use authorizations from the FDA for a vaccine, what he thinks about traveling in 2021, and more. Watch the video below and read on for the transcript. 

Cases Rising in 36 States

So we'll just dive right into it. We've been been kind of comparing and contrasting a lot of different data monitoring websites on COVID and trying to sort of get to the bottom of what's going on here in the last couple of weeks. So in the last seven days, we really have seen a pretty big uptick in case numbers which is concerning.

But what's even more concerning to me in particular is that we're actually starting to see, really see, across a lot of states the hospitalization numbers begin to tick back up again. And that's worrying to me.

So as of last week when we were talking, there were a couple of states that had rising hospitalization rates. But now at this point, it's actually about 36 states that are having rising hospitalization rates from COVID. So that's starting to become a little bit alarming to me.

Luckily, in some places, there are more deaths in some places than in the summertime. But overall in many places, the death numbers and especially the case fatality rates are staying roughly stable. But again, those numbers are going to lag behind the hospitalization rate increase somewhat, so it is at least moderately concerning to me that the hospitalization rates and numbers are creeping back up.

They have not gotten back up to where they were back in the spring and the summer, which is good. But I think we're unfortunately I think going to see a bigger wave here in the next couple of months of not only cases, but hospitalizations and unfortunately continued fatalities from the virus, especially as people start to move indoors because of the cold weather. I think that's probably one of the major drivers here is, is the indoor piece, as the weather has cooled off, people are spending more time inside, which of course exposes them to the virus and to a higher dose of the virus for longer periods of time. So even if they're not gathering in large groups, that's definitely an issue.

I'm actually going to send you guys a couple of websites that I have found where you can compare and contrast some of the the data numbers we're seeing. Now we appear to have done really well, comparatively in Virginia. The numbers, again, everything is pretty stable. And in concert with that, we have continued to kind of move forward with reopening the schools and things like that. But you know government, I mean business-wide, things are staying stable in terms of, I don't think there's any new changes or advancements going on, but we are bringing back a few more students at a time as as things have remained stable.

And I'm going to send you, one of our members who is on this every week, Andy, thank you for sending me the link. I got it on another post is COVID tracking site - covidtracking.com is a great website. Additionally, COVIDActNow, that's the VDH website, there as well.

There's a lot of good information on these websites. You can take the data and play with it, look around, take, compare different metrics over time and look at different scales. And it will actually give you all the historical data for any state that's reported that information.

But if you look at COVIDtracking.com, what you're going to see, and I think this makes sense, the number of tests has gone up. This continued to go up. More and more people are seeking testing all the time, which is great and commiserate with that. The cases have gone up, which makes sense to me, and that's not concerning, but if you actually look on this main page and then you delve down into the data, not only just on this website, but the others as well, you can see the the hospitalizations starting to trend back up unfortunately.

So back in August, there were 55,000ish patients hospitalized across the country on August 1st. And that went down to a low of around 29,000 at the end of September and has ticked back up to about 44,000. So not back up to where we were in the summer, but definitely not trending anymore in a good direction. So that's concerning and the death counts continue to stay around a thousand a day for the most part, which again, you know, continues to be high. So that is a continued problem.

The hope, of course, is that eventually in the next few months, we're going to be seeing a vaccine come out which will help really mitigate this and ,as we've said before, is really going to be the ultimate answer to this problem. So let's take some of your questions.

Decline of Antibodies

"So a study published earlier this week suggested that the level of antibodies may decline more rapidly than previously thought, but don't antibody levels normally decline? If so, do reports like this one shed any light about the length of immunity after infection? Some media stories present results like this as bad news, but I thought things weren't that simple."

Yeah. So I'll take a look at this report. I haven't seen it in particular. We've seen anything in terms of antibody decrement anywhere from three to six months in people so far. It does not surprise me that the antibody levels go down over time and that is normal. So just because the overall antibody level goes down doesn't mean that the body doesn't have memory B cells, which retain the ability to rapidly escalate antibody production for any particular ailment.

And so I would expect the overall amount of antibodies to go down, but probably people do retain the memory B cells to make the antibodies again quickly. Same thing, or I guess the other side of that equation too, is we don't really know whether T-cell immunity truly is a protective and how long that is lasting in people as well. And that's another critical component of immunity that we just don't have a good test for.

There's no easy, convenient way to test for that. It's very specialized testing done in labs with researchers at this point.

All that is to say that I think it's going to stay too soon to really make any definitive comments on immunity, either from the antibody side or the T cell side, for probably honestly a couple of more years and probably well after we get a vaccine in terms of the length of time that the immunity lasts. All immunity does tend to wane over time for the most part.

And it depends...each virus is different. The severity of illness is different. Not all viruses, as we all know at this point, generate a robust immune response that lasts forever. So I think there's still a lot of questions.

I don't necessarily think that, I agree with you, I don't think that this necessarily is bad news. It's another data point. And I think I would just take it in the context of everything else, which is to say, yeah, antibodies generally do decline over time.

The key will be whether someone can regenerate a strong antibody response in what's called rechallenge. So if they get rechallenged with the virus, and I don't know anybody who wants to sign up for that experiment, but if you get rechallenged with the virus, do you produce a strong antibody response quickly? Again, that's really the question and that's up to the body's memory - what's called memory B cells.

Excess Death Numbers

"What are your thoughts about the estimates of excess deaths published by the CDC and others? Does this help us understand the wider impact of the pandemic, for example, by accounting, for deaths that may be caused by people who delay important medical treatment or extra deaths caused by additional people impoverished by lockdowns or pandemic related job loss and the like?"

Yeah, I've been following this data, not just out of CDC, but actually VCU in Richmond has been publishing a lot of this data themselves and probably somewhere around 30ish percent of the excess deaths we have seen since the lockdowns started in March are probably due to something related to the lockdowns.

Again, it doesn't necessarily mean that doing the lockdowns at first was the wrong decision. We did what we thought was best at the time.

But it does mean that lockdowns do have consequences. We did lose people related to, like you said, economic problems and depths of despair related to that, but also from delayed medical care hospitalizations for stroke, heart attacks, and other things have plummeted to very low levels, which is concerning.

It doesn't mean that suddenly these diseases disappeared. It means that those people just aren't seeking care. I know I've had lots of patients that I've had to really strongly convince them to go into an emergency room or into the hospital to get checked out for symptoms, because they wanted to ignore it because they were afraid to go into the hospital because of COVID.

That is a real problem and a real thing that is going on now. Again, it kind of becomes tricky figuring out, well, if we had done nothing, what would the deaths have been just from COVID and then there's no way to quantify or know that.

But I think it's important to try to keep these two things in balance and remember that both sides of this equation have have consequences. So we just need to be proceed cautiously, as we we've been doing, for sure.

But yeah, the excess death numbers do really really concern me for a lot of reasons. The mental health issues have been a serious problem for people. Substance abuse as well has skyrocketed. We are seeing quite a lot of problems related to that. I know in our county here in Chesterfield, where I live, we've lost more children to suicide from mental health problems than have been seriously ill or died from COVID just since March. So we've got some balancing to do there with those things.

Best Case for the End of the Pandemic

"What's the best case for the end of the pandemic? Could life go back to normal, life go back to the 2019 status quo? Once an effective vaccine has been disseminated worldwide, should we expect there to be annual outbreaks and annual vaccination? Might people in vulnerable populations need to continue wearing masks and distancing indefinitely? This article got me thinking about these topics. It quotes a scientist who says this virus isn't one of those that can be eradicated and will likely be around in some form forever."

Yeah, that's been my growing concern is that it essentially, in my own mind, I've sort of come to a, I don't know what the word is you want to use, realization? Acceptance? In some way that probably the virus is endemic at this point, meaning it's going to keep circulating through the population to some degree or another until we get an effective vaccine.

I think that really is going to be the answer. I think going fully back to a normal status quo really is going to hinge on a safe and effective vaccine that we can disseminate broadly.

It's just like all the other outbreaks in the past, smallpox, polio, all of these other things, diptheria, what have you...they're going to continue to spread no matter what we do until we get a vaccine.

We can do some of these things that we're doing, the distancing, the masking, being more cautious about crowds, etc. And that's going to help mitigate things. But I don't think we're going to be able to stamp it out or eradicate it through public health means alone through these non-sort-of pharmacologic interventions.

We're going to have to figure out how to get a vaccine deployed in order to actually fix the problem.

And I think, so you say annual outbreaks, I think we'll continue to have quarterly outbreaks like we're seeing now. It's been about once a quarter where we have these big upswings in cases and hospitalizations, that seems to happen on about a quarterly basis at this point. I think we will continue to see that go on until we have a vaccine, unfortunately. So that's kind of where I am at on that right now.

So hope that answers your question, Andy, but yeah, I mean, unfortunately I think from a medical perspective, we've got, we've just have to have a vaccine. That's the best and most efficient answer to kind of putting this to a halt.

Mass Rallies

"I'm terrified about these mass rallies that the man in the white house is holding. Is there any doubt in your mind that COVID numbers are going to rise and that people will die from this behavior?"

I think that probably there certainly will probably be some cases and such related to any kind of mass gathering of people, whether that's related to politics or anything else. I don't know how many of those cases will result in people getting really sick and dying?

Like I said, any mass rally is a cause for concern. I know I've certainly advised people, family members included, not to attend mass rallies of any kind, whether it's political, religious, or anything else. Same thing goes for, honestly, protests. It's the same thing, right?

Any of these things are a problem because you're gathering large groups of people together. And depending on what side of the equation you're on, you tend to worry about one gathering or the other. And I've seen that with folks, not to put too fine a point on it, but I mean, they're all a problem.

I think that we should be avoiding these massive gatherings no matter what, because I think they are dangerous in a lot of ways, especially for vulnerable people.

And the big problem is it's not the vulnerable people going to the rallies necessarily. It's all of the young people going into the rallies, getting asymptomatically ill, and then going home and spreading it to everyone else. That being said, from the data I've seen from not only from people who've tried to track outbreaks and link outbreaks, I've not seen big outbreaks linked to to many of these mass gatherings where there's the protests or political rallies or whatever.

You've seen some of these things. And you've seen some of these super spreader events, even from smaller gatherings, like unfortunately all the people who got infected at the White House related to Justice Barrett's nomination ceremony, or a press conference, a lot of people got infected there. So it doesn't even have to be that large of a crowd. It's sort of random in that way.

But yeah, I mean, I think any large gathering of people more than 50 to 100 people, really at one place, especially if people are not doing anything in terms of being diligent about masking, distancing, washing, etc, it is a cause for concern.

Remaining Endemic After Vaccination?

"About the end game, the scientist in that article I cited suggests that the virus will remain endemic after vaccination, at least at some level, do you think that's possible or perhaps likely?

Probably, because I don't think that vaccine uptake will be very swift. I think that the vaccine probably will take a long time to sort of get through the population. It also depends too, right, a little bit on how the vaccine works.

So if it's a one and done like say the smallpox vaccine, for example, or what have you, it's sort of a one and done. You get vaccinated, and then you're good forever.

If it's more like the flu vaccine where you have to take it annually, we're going to have a really hard time getting people to do that on an annual basis. We have a hard enough time getting people to take a flu shot on an annual basis so that the flu continues to circulate year after year. I think he's probably modeling that idea after flu vaccination, which makes a lot of sense, a lot of good sense for a lot of reasons.

So I think that's probably where he's getting that line of reasoning, which makes, again, I can totally sympathize with that line of rationale. So I guess it really depends on what kind of vaccine we get. If we get this sort of boom one and done, you're immune forever, then we could probably stamp it out like polio, smallpox.

A lot of these other things, if it's more like flu where the immunity wanes or the virus changes too rapidly, year over year, then we're going to continue to suffer with this on a fairly regular basis, probably not to this degree certainly, but we will continue to have these problems.

So I think it depends on how good the vaccine is and and how good the uptake of the vaccine is in the population, which really gets to not only the efficacy of the vaccine, but the safety features too.

Flu shots by and large are pretty benign for the most part. They don't work as well as we would like them to, but they do work fairly well, but they don't cause a lot of side effects. And so I'm hoping that we can get something like that for the COVID vaccine. There tends to be some higher side effect rates from the trials that we've seen so far, but hopefully by the time they're done with the phase three trials, they'll have figured out how to mitigate some of those to a certain degree. And I trust that they will.

But it's just gonna take a little bit of time to make sure that it's safe and effective because that's really going to determine the uptake rate. You know, people aren't going to take a vaccine if they know they're going to get really sick from it. It's going to be hard to convince people. We're going to have to focus on that.

Emergency Use Authorization for a Vaccine?

"What are your thoughts about a EUA for the COVID vaccine?

So emergency use authorization is what she's talking about for those who don't know, that's where the FDA sort of says, "well, we don't have all the data that we really would like to have, but the preponderance of the data is reasonable and we think it's safe enough to go ahead and move forward with things."

And honestly I think it's okay for the vaccines as well. We've been operating under EUAs for most everything since the start of the pandemic.

That includes not only some of the drugs we've been using, like Remdesivir, Tocilizumab, and some of the other things that are out there, the plasma treatments have been running under an EUA, but actually most people don't realize, all the tests for COVID from the PCRs to the antibodies, all of that stuff, none of that is fully FDA approved. That's all running under an emergency use authorization because there just wasn't time to complete all the necessary studies.

I think it's fine as long as we have people in not only the FDA, but the wider sort of medical community, watching the data closely and being cautious. I think that EUAs can be fine to use especially if the data looks really safe for the most part. You can never be certain, but you can't really get to total certainty from the longer FDA review process either.

We all know that drugs get pulled off the market even after being fully vetted and approved for years, because things do happen. But that being said, I think that EUAs are reasonable. I think that our government overall and the FDA is taking a pretty measured approach to the vaccine development and deployment and the safety monitoring, and in most of the Western world, I think that's true.

We've had some of the trials halted a few times when there's been any hint that there's a serious problem. Luckily, so far everything has turned out to be okay.

I know someone unfortunately passed away in the AstraZeneca trial, I believe it was last week, and it initially got reported that they were in the vaccine group, but it turns out that that was completely false. They were in the placebo group. And it wasn't even clear what they passed away from.

I think people are watching the data really closely, which is good. I'm encouraged by that. I think it's okay if we use the EUA method, especially because when we first roll out the vaccines, it's not like we're going to have enough to give to everybody. We're not going to be giving it to everybody at once.

We're probably going to give it to relatively small groups at a time. And so that's a good way to introduce something like that into the population.

Not to say that some people should be Guinea pigs, but it's going to go to healthcare workers and the highest risk people first, because they're most likely to benefit from the vaccine. Even if there is a slightly higher side effect rate than, than you might like, they still will get some benefit from it because of their risk level.

Traveling in 2021?

"Do you have any thoughts about how safe travel might be in 2021. My wife really wants to go back to France and is hoping that conditions will be safe for that in the spring or summer?" 

Yeah, I'm wondering the same thing. My family really would like to travel next summer as well, out of the main land here. I think it's really going to depend on a vaccine. I know France, I think Spain, and several other European countries are actually going back down into a deeper lockdown than then they have been in the summer because their case rates are going up so fast.

So again, I think we're going to continue to see waves of this. Maybe not as pronounced as we saw back in March, April, but I think we're going to continue to see waves of this. And I think that international travel is probably going to continue to be pretty restricted until we get this under better control.

And again, I think that's the vaccine is really the only optimal the only viable solution for that in the medium term.

So yeah, unfortunately, I'm not pessimistic about international travel for next year, but I'm not exactly optimistic about it either right now. I really would like to see them to start roll out the vaccine first part of next year. And I think if that can begin then we can start to see some sort of end of the tunnel... That's the word I was looking for or phrase that I was looking for. I think that really everything hinges on that.

Humidity with the Virus?

"How does humidity play into the virus transmission?" 

I'm not sure that it does too much, at least I haven't seen any data around that. So I'm not certain is the short answer to your question. I think really it's just about overall ventilation and air flow rather than about humidity levels. So more air flow, better ventilation is better in terms of reducing viral transmission risk.

"Is it useful to keep indoor humidity at a specific level? What is too dry and what is too wet for health?"

I don't know. I don't know what is a good or specific level of humidity to keep it at. Again, I haven't seen any specific data showing that the virus is better or worse in specific humidity levels. You probably want to keep it at a moderate range, low humidity, really dry air is bad in general for a lot of reasons for people with respiratory illness in general and really high is bad. So it sort of Goldilocks you know, somewhere in the nineties is probably too high. But I have to do a little bit more research to answer that question more specifically.